Rancho Pacific Home Care

Type of visit: POC

Licensing Program Analyst (LPA) Amy Rodgers conducted an Plan of Correction case Management visit at the facility. LPA Rodgers was greeted by Licensee Monica Siharath while at the facility after the annual visit. During today’s visit, LPA was provided proof of current CPR certificates for staff and current Re-appraisals for residents. LPA and Licensee also reviewed regulations for resident annual medical exams and medication administration. No deficiencies were observed or cited during this case management visit. An exit interview was conducted with Licensee Siharath and a copy of this report, along with the Licensee/Appeal Rights (LIC 9058 3/22) were provided to the facility manager at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Aug 29, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit with care staff Joselito Carambas. Siera Navaska also joined the visit for a brief time. A tour of the facility was conducted, including all resident rooms, staff areas, common areas, bathrooms, kitchen, garage, and outside grounds. Due to time constraints, additional components of the annual inspection will need to be continued at a later date. During review of medication storage and documentation, LPA observed unsecured medications, medications accessible in resident rooms, and medication records that did not match physician orders for 4 of 5 residents. LPA also observed Pre-pored containers for 5 of 6 residents in medication cart. The facility does not maintain a MAR. During review of resident records, LPA found reappraisals were not current for R2, R3, R4, and R5. During review of personnel records Staff #1(S1) and Staff #2(S2) are without current CPR/First Aid certification. Night staff (S1) also lacked required CPR/First Aid training. Deficiencies were cited today per California Code of Regulations, Title 22 (see the attached LIC 809-D pages). Plans of Correction were discussed with Caregiver Joselito Carambas. LPA will return on a subsequent day to complete the remaining portions of the annual inspection. An exit interview was conducted with Caregiver Joselito Carambas, to whom a copy of this report, the LIC 809-D pages, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Aug 29, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(h)(1) · Plan of correction due date: Aug 30, 2026

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place... This requirement is not met as evidenced by: Based on observation, LPA observed medications sitting on top of the medication cart upon entry, and the cart was unlocked with keys left in the lock. During the tour, PRN and prescribed medications were observed in R2’s room and in R3/R4’s shared room, making them accessible to 4 of 5 residents. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2026

Plan of correction: LPA had Staff #1 lock medication in cart and audit all Resident rooms for stored medciation and lock in medication cart. LIcensee will conduct outside source training to all staff and themselves regarding medciation storage by 9/30/2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC8765(h)(6) · Plan of correction due date: Aug 30, 2026

(6) Centrally stored medication records shall be maintained to ensure that medication is given as prescribed. This requirement is not met as evidenced by: Based on record review and observation, LPA found that the physician‑ordered medication lists do not match the medications maintained for 4 of 5 residents. The facility does not maintain a MAR, resulting in inaccurate and incomplete centrally stored medication records. This poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2026

Plan of correction: LPA will conduct audit of R1-R5 medcations to assure physcians orders prescriptions corrilate with medcations given by POC Date. LIcensee will conduct outside source training to all staff and themselves regarding medciation storage by 9/30/2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87563(h)(1) · Plan of correction due date: Sep 30, 2026

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Based on observation and interview , the licensee did not comply with the section cited above in 2 of 6 (R2 and R4) which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2026

Plan of correction: Licensee will ensure that R2 and R4 completes their annual routine physical/medical visit. (In cases where the RP refuses the annual visit, Licensee will document such refusal in writing.) Licensee agreed to send proof of completion to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(c) · Plan of correction due date: Sep 30, 2026

The licensee shall conduct a reappraisal of each resident as frequently as necessary to ensure that the resident's needs can be met. Based on record review, LPA found that R2, R3, R4, and R5 do not have current reappraisals as required. The lack of updated reappraisals limits the facility’s ability to properly assess residents’ changing needs and ensure appropriate care. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2026

Plan of correction: Licensee will ensure that R2-R5 completes their Re-Aprriasals by POC date,Licensee agreed to send proof of completion to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Sep 30, 2026

87411(c)(1)All personnel responsible for providing care shall have current CPR and First Aid certification. This requirement is not met as evidenced by: Based on record review, LPA found that (S1 and S2) staff responsible for providing care do not have current CPR and First Aid certification. This poses a potential health, safety, and personal rights risk to 6 of 6 persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2026

Plan of correction: Licensee shall ensure that all staff responsible for providing care obtain current CPR/First Aid certification and submit proof of completed certification to LPA by the POC date

From the deficiency page — Deficiency type: Type B · Section cited: HSC87515(a) · Plan of correction due date: Sep 30, 2026

87415(a)Night staff shall be trained in first aid as required in Section 87465 and shall be available to assist in caring for residents in the event of an emergency. Based on record review and interview, LPA found that night staff do not have current CPR/First Aid training as required. This poses a potential health, safety, and personal rights risk to 6 of 6 persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2026

Plan of correction: Licensee shall ensure that all staff responsible for providing care at night obtain current First Aid/CPR certification and submit proof of completed certification to LPA by the POC date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(H)(5) · Plan of correction due date: Sep 30, 2026

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in 5 of 5 persons which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2026

Plan of correction: Licensee will immediately discontinue the practice of pre-pouring medications. Licensee will retrain all staff responsible for medication assistance and medication handling, ensuring medications are dispensed only from the original pharmacy container at the time of administration. Licensee will submit proof of staff retraining to LPA by the POC.

Allegation investigated: Administrator was not present at facility a sufficient number of hours

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Licensee Monica Siharath. During today's visit, LPA observed residents in care and briefly spoke with the Licensee. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Administrator was not present at the facility a sufficient number of hours. Review of the facility’s licensing profile listed Staff 1 (S1) as the Administrator for the facility. [Licensee was provided with an LIC811 Confidential Names List to identify S1] Interviews with the Licensee and residents revealed that S1 was at the facility 3-4 days a week for a few hours during the day and S1 had part-time employment outside of the facility. Continued on LIC9099-C page... Substantiated S1 was present at the facility in the late evening to provide overnight on-call supervision. Interviews asking about S1’s job responsibilities revealed that S1 provided showers and bed baths for 1 to 2 residents during the day. Interviews with residents and the Licensee revealed that the Licensee was at the facility most days of the week between a couple of hours a day to all day and was also on call. Residents stated they would voice any concerns to the Licensee instead of S1 and noted the Licensee as the owner of the facility. Interviews with the Licensee stated that S1 was responsible for providing direct resident care to one resident and was also responsible for overnight care, completing paperwork and scheduling staff. During visits to the facility on 5/23/2025, 6/5/2025, and 8/7/2025, LPA Borunda interacted with the Licensee to obtain resident and staff records and LPA did not have any interactions with S1. The Department attempted to interview S1 for the investigation, however, S1 did not respond to LPA’s multiple contact attempts. Additionally, review of the Administrator Certificate lists revealed that the Licensee’s most recent Administrator Certificate expired on 1/18/2019 and as of 8/7/2025, the Licensee did not have a current active Administrator Certificate. Interviews with the Licensee confirmed that they did not have a current Administrator Certificate. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Licensee Monica Siharath, whose signature below confirms receipt of a copy of this report, LIC811, and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 08-AS-20250514111838

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 5, 2025

87405(a) … The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section… This requirement has not been met as evidenced by: Based on interview and record review, S1 was not at the facility enough hours to provide facility oversight. This poses a potential personal rights risk to 6 of 6 residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Licensee stated that she will enroll in classes for the Administrator Certificate in order to obtain a valid Administrator Certificate. Licensee will provide proof of enrollment in Administrator Certificate Training to the Department by POC due date of 9/5/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Dominador "Pong" Dacanay. Licensee Monica Siharath arrived during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents and has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 6 residents, 5 of which were non-ambulatory. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident and staff bedrooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 105.2 and 105.8 degrees Fahrenheit in bathrooms for resident use. The facility’s internal temperature was measured at 77 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Monica Siharath, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 32 degrees Fahrenheit, and the facility freezer was kept at -6 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Continued on LIC809-C page… Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Resident records contained a signed admission agreement, initial medical assessment, updated annual reappraisal, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. LPA provided Licensee with consultation and guidance regarding the regulation changes that became effective 1/1/2025. LPA was away from the facility for approximately one hour between 12:00pm and 1:00pm. No deficiencies were cited on today’s date. An exit interview was conducted with Licensee Monica Siharath, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct an annual continuation from 5/31/2024. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Joselito Carambas. Licensee Monica Siharath arrived during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 6 residents, 2 ambulatory and 4 non-ambulatory. 2 residents were receiving hospice services. The Administrator for the facility is Brandon Navasak and their certificate was valid and current. During visits on 5/31/2024 and 7/30/2024, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 133.0 degrees Fahrenheit in a private resident bathroom and 120.7 degrees Fahrenheit in a common bathroom. Licensee turned down the water heater during the visit and the water was remeasured at 119.8 degrees Fahrenheit before the end of the visit. The facility’s internal temperature was measured at 76 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Monica Siharath, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Continued on LIC809-C page… Staff present at the facility during the time of the inspection had a criminal background clearance and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. The Licensee will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. The following deficiency was cited for hot water temperature and noted on the attached LIC809-D page. An exit interview was conducted with Licensee Monica Siharath, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Rebecca Ruiz and Ryan Fulton conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with Caregiver Victoria Dequina. Administrator Monica Siharath arrived during the visit. During today's visit, LPAs toured the facility, reviewed facility records, and observed residents in care. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. The following deficiency regarding incontinence care was cited and noted on the attached LIC809-D page. An exit interview was conducted with Administrator Monica Siharath, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, May 31, 2024

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Jun 14, 2024

87625 (b) ... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement has not been met as evidenced by: Based on LPA observation, the licensee did not ensure that the facility remained free of incontinence odors. This poses a potential personal rights risk to 6 of 6 residents in care.the state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: Administrator will submit the log to the Department by POC due date of 6/14/2024.